The Trauma that Remains

Suppose that a soldier, freshly home from Iraq, is made to take a test. He or she is asked to describe the following statements as true or false: I usually feel that life is worthwhile. False. Sometimes I feel as if I must injure myself or someone else. True. Most of the time, I wish I were dead. True. This soldier is at risk for suffering from Post Traumatic Stress Disorder (PTSD). Symptoms can include flashbacks or nightmares, lack of sleep, panic, and violent or explosive outbursts.

Right now such testing is not in place. The House Committee on Veterans Affairs met last week to discuss options for dealing with the potential problems with returning soldiers and PTSD. (The government's benefits system for the disorder has come in for notabe criticism recently.) At the hearing, Minnesota Representative Tim Walz, who served overseas in Italy during Operation Enduring Freedom, described feeling concerned that there was no psychological examination administered on him and as fellow soldiers upon return. "We had extensive physical screenings when we came back," Walz said. "What we got was a 20 minute talk with the chaplain and they showed us The Horse Whisperer … I want to err on the clinical side of diagnosis."

A recent Army study found that more than one-third of veterans returning Iraq veterans have sought help for PTSD-related symptoms. Beth Hudnall Stamm, director of telehealth and principal investigator of the Institute of Rural Health at Idaho State University, estimates that 6 to 8 percent of veterans suffer from life time PTSD, of which 4 percent are chronic cases. She estimates that anywhere from 6 to 20 percent of this generation of veterans will suffer from some form of PTSD, but other studies suggest that number might be as high as nearly 40 percent.

Clinical and forensic psychologist Saul Rosenberg, who testified at the hearing, envisions a system where solders would be given psychiatric evaluations upon entering the military, to get a baseline, then tested once again upon return from combat operations to flag those who might be at risk for developing PTSD. Psychologists and regular doctors could follow up with these soldiers. Such testing could allow mental health professionals to "identify those at greatest risk;" Rosenberg estimates the initial screenings would cost the government about $60 per returning soldier.

Since so many veterans come to their primary care physicians or go to their local Veterans Administration (VA) hospital with symptoms related to PTSD, Rosenberg said he would like to see the renowned VA computer diagnosis system, VistA, used during regular doctor visits to assist with diagnosis. This would help primary care doctors become educated about PTSD, which many experts view as a normal reaction to abnormal levels of violence or abuse.

Although the VA is often cited as the world leader in dealing with PTSD thanks to the quality medical care veterans receive, a number of problems remain. An inspector general's report released this month by the Department of Veterans Affairs indicated that about 1,000 veterans undergoing treatment with the VA commit suicide every year. (An average of about 5,000 veterans overall commit suicide each year.) Due to a lack of funding support for health care professionals, veterans under the VA system are on a waiting list for 6 months before they can see an expert -- a prime period during which they could be effectively treated for PTSD before symptoms worsen.

Meanwhile, National Guard and Reserve troops, who have faced radically heightened deployment levels for the last several years, lack access to quality VA hospital care; they are under a different system, TRICARE, run through the Department of Defense.

Consistent record-keeping is also lacking under the current system. While enrolled in the military, soldiers receive TRICARE, but enlisted soldiers then switch over to the VA system once they exit the military and become veterans. As recently reported, records are rarely transferred effectively from the DOD to the VA. If TRICARE merged its record-keeping system with the VA's VistA system, then the two could work together to create a working database of PTSD symptoms and patients, which could include information on which treatments are effective for which kinds of symptoms. At Wednesday's hearing, Rosenberg also pointed out that veterans often lack access to their own records, so if they're treated at more than one facility, or if they suffer from a brain injury and can't effectively care for themselves, they receive a significantly reduced quality of care.

Robert Bray of the Thought Field Therapy Center of San Diego said that the reimbursements given by TRICARE for treating veterans are so modest in comparison to private practice as to discourage psychologists and psychiatrists from treating veterans with PTSD symptoms. He advocates making veterans' health coverage similar to a private insurance policy that would allow them to be treated in private practice and have the VA or DOD cover most of the bill, rather than dealing with the long waiting periods for an appointment in the VA system.

Many experts advocate working with existing community systems to enhance the quality of care for veterans. Some veterans live in rural areas, far away from a VA health care facility. At the hearing, Laura Rosenberg, president and CEO of the National Council for Community Behavioral Healthcare, advocated extending benefits to local doctors and training them to identify symptoms of PTSD. (As Laura Rosenberg cautioned in explaining resistance to such community-based case on the part of the VA, "A closed system tends to want to stay closed. You can manage it better. You feel more in control of it.") Sometimes alternative treatments can be beneficial as well. One mentioned at the hearing is offered by Sand Storm Productions, which allowed former Marine Sean Huze to effectively deal with his PTSD through playwriting. Typically, however, with research on PTSD still underdeveloped, the VA won't approve such alternative programs because they are not on a set list of treatments.

Are there near-term prospects for improvements to the system? The Veterans Affairs committee did recently send legislation to the House floor that would extend the current period of health-care eligibility to veterans who served in the Persian Gulf and future conflicts from two years to five years after discharge or release from the military. (Some injuries, especially mental stress injuries, may not be fully evident until after two years.)

In part, action on this front, as with everything in government, comes down to budget politics. The Veterans Affairs Committee has already put a 30 percent increase into budget bills for veterans, committee chairman Bob Filner noted. In the last round of budget bills, Filner said he requested an additional $5 billion for veterans' health care spending, but received $3.5 billion. The committee will likely try to work additional funding for veterans' health care into each war supplemental bill as well as into the fiscal year budgets. Some estimates say that the cost of caring for returning Iraq and Afghanistan veterans could be anywhere from $300 to $500 billion over the next 10 years. Ultimately, it becomes a question of budget priorities.

Beyond funding improvement lie systemic reforms. The VA will likely have to move from a piecemeal approach to treating PTSD to a more comprehensive one. If every soldier returning from overseas combat operations underwent the same testing and screening, the stigma would be reduced and doctors could gather valuable data to more effectively treat PTSD. Meanwhile, partnership with community health care centers would allow soldiers who live far from VA facilities to be treated close to home more quickly.

Ultimately, if the VA combines its refined treatment of some patients with comprehensive screening and follow-up with this generation of veterans, mental health professionals could go a long way in developing effective PTSD treatments for everyone. "I think we have an opportunity here because people look at veterans in a different way," said Texas Representative Ciro Rodriguez at the hearing. "We could use our position here to begin to make changes that become models for the other parts of society."